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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206795
Report Date: 08/11/2022
Date Signed: 08/11/2022 11:00:17 AM


Document Has Been Signed on 08/11/2022 11:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:BLOSSOM CREEKS ASSISTED LIVINGFACILITY NUMBER:
107206795
ADMINISTRATOR:SAMRA, RAJVINDER KFACILITY TYPE:
740
ADDRESS:501 SOUTH APRICOT AVETELEPHONE:
(559) 598-9515
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 6DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH: Licensee Rajvinder SamraTIME COMPLETED:
11:00 PM
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On 8/11/22, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection-Infection Control. LPA met with Licensee Rajvinder Samra and stated the purpose of the visit.

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one
entrance/exit point. Facility staff observed with facial coverings. Facility appeared clean with no obstruction or
fire clearance issues. Hand sanitizer was readily available to residents and visitors. Hand washing and other
various Covid-19 related signs were observed in the common areas.

Sharp items are kept locked in the kitchen cabinet. cleaning supplies were secured in a locked cabinet in the laundry room. Medications were secured in a locked closet in the living room. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the Kitchen was last serviced on 5/5/2022 and was fully charged. Cleaning and PPE supplies were locked in the garage. Bathrooms have trash cans with lids. Hand washing posters were observed in the bathrooms by the sink.

Staff records were reviewed for good health, infection control training. Residents wear masks when away from
the community. Resident’s files have updated emergency contact information. No deficiencies were observed.

LPA is requesting the following documents be submitted to the Fresno CCL office by 8/18/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC
309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610E),
Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Licensee. Report signed on-site and printed copy provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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